Dermatology Online Journal

Abstract

Introduction

Despite the clinical relevance of the nails, nail anatomy, pathology and diseases are given inadequate attention in medical school and other health care training programs. The traditional approaches to teaching are lectures, supervised instruction at the bedside or in the clinic, and review of textbooks. Lectures on the nails are useful but they are either minimally employed or absent from medical training. Bedside or clinical teaching is not consistent from student to student. Textbook teaching can be very useful. However, it is often problematic because the image quality achievable in a book is quite variable, and it can be difficult to motivate residents, students, as well as fully-trained physicians to read books to systematically learn about the nails.

Our software development group at the University of Washington has been developing computer programs that help medical personnel learn a variety of image-based diagnostic tasks. Our previous work has focused on the most common image-based tests in the clinical laboratory and includes GramStain-Tutor (Cookson et al., 1994; Mandel et al 1996) which teaches the intepretation of direct Gram stains, Urinalysis-Tutor (Henderson et al, 1995) which teaches the microscopic examination of urine sediment, and many others (Astion et al., 1993, 1995; for review see Astion et al., 1996).

The computer program we describe here, Nail-Tutor^TM (Lippincot-Raven Publishers, Philadelphia, PA; Novartis Pharmaceuticals, East Hanover, NJ), represents an application of our underlying software engine to an important educational problem in dermatology. Nail-Tutor^TM is an image-based, personal computer program for medical doctors, medical students, and other health care trainees that uses about 150 images and illustrations to systematically teach the anatomy, pathologic patterns, and disorders of the nails. The educational objectives of Nail-Tutor^TM are that users who have completed the program should be able do the following: 1) describe with proper medical terminology the normal anatomy of the nail unit including its blood supply, 2) identify the parts of the history, physical exam, and laboratory exam that are most relevant to patients who have nail lesions, 3) use proper medical terminology to name and describe the most common patterns of nail unit pathology, and to state which part or parts of the nail unit (i.e., nail plate and matrix, nail bed, nail folds) is/are most likely to be involved for a particular pattern of pathology, 4) look at an image of diseased nails, identify the pattern of pathology present, and state the differential diagnosis for that pattern of pathology, 5) describe nail changes that can be classified as normal variants or normally associated with aging, 6) name the major acquired disorders and congenital disorders of the nails, 7) identify nail changes that may reflect underlying systemic disease, and 8) describe the typical patterns of pathology and other key clinical findings associated with the most common types of nail disorders.

Methods

An early version of Nail-Tutor^TM was reviewed by dermatologists, medical students and general internists from within and outside the University of Washington. These users provided detailed feedback that was used to complete the final version of the tutorial.

Program Description

Figure 1
Figure 1: Schematic of the Nail-Tutor Computer Program. More detail on the Acquired Disease section is shown in figure 2 (below).

Figure 2
Figure 2: Schematic of the Acquired Disease section of the tutorial.

Figure 3
Figure 3: The main menu screen of Nail-Tutor. The program is completely operated by making selections with the mouse.

Figure 4
Figure 4: A screen captured from the Introduction section of Nail-Tutor.TM

Figure 5
Figure 5: This screen from the Introduction section of Nail-Tutor shows the nail unit. The nail matrix is highlighted in white because the button labeled "Nail-Matrix" has been selected by the user.

Figure 6a	Figure 6b

In the section on patterns of nail unit pathology, the patterns are classified according to the component(s) of the nail unit most involved. Pathological changes are shown using high resolution images labeled with arrows and text, and for most of the pathological changes there is bulleted text which describes the change and lists the differential diagnosis. For some of the images, the user can click an "overlay" button to completely highlight a given feature in that image. For example, in the screen showing dystrophy-longitudinal ridging (see figure 6), the longitudinal ridges can be highlighted in green when the user clicks an "overlay" button. Similarly, in an image which depicts triangular lunulae, the triangular lunlae can be completely highlighted in green (see figure 7).

Figure 7a	Figure 7b

The section on the classification of nail disorders teaches disorders of the nail unit, emphasizing 1) classification, 2) typical appearance (using labeled images), and 3) key clinical facts. Nail disorders include acquired diseases, congenital diseases, and changes that occur with aging. Acquired diseases include dermatologic diseases, systemic diseases, fungal infection, other infections, color changes, changes caused by medications, benign tumors, malignant tumors, and trauma. Typical example screens from the nail disorders section are shown in figure 8, which shows one of 4 examples of psoriasis, and figure 9 , which is taken from the onychomycosis section and which shows distal subungual onychomycosis.

Figure 8	Figure 9

The image atlas section of the program allows one-click access to the most important images from the Nail Pathology and the Classification of Nail Disorders sections of the Nail-Tutor^TM without having to navigate through the program. Users can access images by pathologic description (e.g., Splitting-Lamellar Dystrophy) or by nail disorders (e.g. Onychomycosis-Distal Subungual). Thirty-two of the images in the Pathology section and 49 images in the Nail Disorders section can be accessed.

Figure 10a	Figure 10b

Images can be viewed one or two at a time. This is illustrated in Figure 10 , which shows the screen that resulted when the user asked to compare two different patterns of pathology which effect the nail plate and matrix: 1) hypertrophy-pachyonychia congenita, and 2) hypertrophy-onychogryphosis. The image atlas is useful for comparing images and as a rapid reference. The final exam contains 20 image-based, multiple-choice questions of varying degrees of difficulty which cover the main topics presented in Nail-Tutor^TM. Detailed answers are provided immediately after each question is completed. At the end of the exam, the examinee receives his or her score. An example of an exam question and answer is shown in figures 11 and 12. The question asks the user to recognize clubbing.

Discussion

For family practitioners, internists, and dermatologists, Nail-Tutor^TM is primarily for continuing education. The program is accredited by the American Academy of Dermatology for 3 hours of category I CME, and is useful as a review or as a tool for learning material that might not have been emphasized during professional training. Nail-Tutor^TM is also useful as a reference since clinical cases can often be clarified by using the program, especially the image atlas, for comparison and contrast.

Nail-Tutor^TM is not a textbook on computer. Rather, the program takes advantage of computer technology to teach nail anatomy, pathology, and diseases in ways that cannot be easily duplicated by textbooks or supervised instruction. Examples of such computer methods include:

1. the use of animation (video clip),
2. use of hypertext to define key terms,
3. use of optional overlays to highlight areas of interest in an image (figures 6, 7),
4. the ability to show key images side by side (figure 10)
5. immediate detailed feedback on exam questions (figures 11, 12).

The approach to teaching shown in Nail-Tutor^TM can be applied to many problems in medicine. Other tutorials of interest to general practitioners and dermatologists that we are currently completing include a genital ulcer disease tutorial, a clinical mycology tutorial, a clinical parasitology tutorial, a tutorial on the principles and practice of microscopy, and others. Our plan is to continue to develop, distribute, and evaluate the educational effectiveness of our tutorials.

Acknowledgement:The authors thank Dale Davis for developing illustrations, Adam Orkand for help with all aspects of the program, Dr. Seung -Joo Kang for providing the initial idea to develop the program, and Drs. Stephan Billstein and Andrew Morgan , for helpful comments and images.

References

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3. Henderson P, Phillips C, Bien C, Kalet N, Pagliaro L, Fine JS, Orkand A, Astion M. Urinalysis-Tutor: A computer program that teaches the microscopic examination of urine sediment. Clin Chem. 1995; 41: S203-204 (abstract).

4. Astion ML, Orkand AR, Olsen GB, Pagliaro LJ, Wener MH. ANA-Tutor: a computer program that teaches the anti-nuclear antibody test. Lab Med 1993; 24:341-344.

5. Astion ML, Rank J, Wener MH, Torvik P, Schneider JB, Killingsworth LM. Electrophoresis Tutor: an image-based personal computer program that teaches the clinical interpretation of protein electrophoresis patterns of serum, urine, and cerebrospinal fluid. Clin Chem. 1995; 41:1328-1332.

6. Astion ML, LeCrone CN, Cookson BT, Orkand AR, Curtis JD, Pagliaro L, Wener MH, McGonagle L, Fine JS. Laboratory-Tutors: personal computer programs that teach the interpretation of image-based laboratory tests. Clin Lab Sci 1996; 9: 44-47.

© 1997 Dermatology Online Journal for 
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